Healthcare Provider Details

I. General information

NPI: 1316026339
Provider Name (Legal Business Name): MRS. GWENDOLYN MILES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17707 STUDEBAKER RD
CERRITOS CA
90703-2640
US

IV. Provider business mailing address

11958 AGNES ST
CERRITOS CA
90703-6902
US

V. Phone/Fax

Practice location:
  • Phone: 562-402-0688
  • Fax: 562-402-3032
Mailing address:
  • Phone: 562-403-0113
  • Fax: 562-402-3032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: